The Palliative Approach Toolkit - CareSearch · 2015-04-19 · These educational flip charts are...

The Palliative Approach ToolkitEducational Flipcharts

These educational flip charts are not a stand-alone resource. Please consult the PA Toolkit Modules for further information and references.

Delirium

Dyspnoea

Nutrition and hydration

Pain

Oral care

Pain is a subjective experience, occurring when and where the resident says it does.

“Pain is a more terrible lord of mankind than even death itself.”Albert Schweitzer

Pain

Pain is a subjective experience, occurring when and where the resident says it does.

“Pain is a more terrible lord of mankind than even death itself.”Albert Schweitzer

Pain

Facilitators notes:

Scope:

This module is appropriate for:

Careworkers (assistants-in-nursing)

Materials needed:

Abbey pain scale form (from PA Toolkit)

Visual analogue (0-10) pain scale ruler

Learning Objectives

By the completion of the session participants will be able to:

•definepain

•understandhowtoidentifypaininresidents who can and cannot communicate

•identifyappropriatenon-pharmacologicalapproaches to treating pain

•understand,onabasiclevel,theinterventions that nursing and medical staff may utilise.

Key Points

•Painisasubjectiveexperienceoccurringwhen and where the resident says it does.

•Olderpeoplemaydeny‘pain’,insteadusingwordslike‘ache’,‘soreness’and‘stabbing’.

•Painismorethanjustaphysicalsymptom.

•Theexperienceandperceptionofpainisstronglyinfluencedbyaresident’spreviouspainexperiences,culture,spiritualbeliefs,socialrelationshipsandotherphysicalsymptomstheymaybeexperiencing.

•In1931,theFrenchmedicalmissionaryDr.AlbertSchweitzerwrote:‘Painisamoreterriblelordofmankindthanevendeathitself’.

Ask the group what he meant by that.

Pain

See: Recognise and assess pain

Ask

“How bad is your pain? Givemeascoreoutoften”

or

‘Whichofthesewordsdescribes how bad your painis?’

No pain Worst possible

pain

Moderate pain

0 1 2 3 4 5 6 7 8 9 10

No pain

Worst possible pain

Mild pain

Moderate pain

Severe pain

Very Severe pain


Ask

“How bad is your pain? Give me a score out of ten”

or

‘Which of these words describes how bad your pain is?’

No pain Worstpossible

pain

Moderatepain

0 1 2 3 4 5 6 7 8 9 10

No pain

Worstpossible pain

Mildpain

Moderatepain

Severepain

VerySeverepain

Facilitators notes:


If the resident can communicate

Asktheresidentiftheyhaveanypain.

Tips

•Olderpeoplemaydeny‘pain’,insteadtrywordslike‘ache’,‘soreness’and‘stabbing‘.

•Mostpaininolderpeopleisrelatedtoactivity. Askthemwhentheyaremoving,transferring, being turned in bed; not when they are at rest.

•Allowenoughtimefortheresidenttothinkaboutthe question and reply.

•Askmorethanonequestion,suchas“Doesithurtanywhere?”or“Doyouhaveanyachingorsoreness?”or“Doyouhaveanypainordiscomfort?

Severity of pain

Ask the resident

‘Howbadisyourpain?Givemeascoreoutoften’

Or

Gettheresidenttolookatavisualscalewhichshoulduse large clear letters/numbers and be presented under good lighting.

Everyone has their own pain threshold

Itisunfairandofnousetocomparethescoresofdifferent residents.

Whatismostimportantiswhetherthescorechangesovertimeforeachresident.

Important

If a resident rates their pain as severe or they report chest pains or have difficulty breathing: Treat it as an emergency and call a nurse immediately.

See: Recognise and assess painResident who cannot communicate

Whatisimportant?

•behaviours

•facialexpressions

Especially important when they change over time


What is important?

• behaviours

• facial expressions

Especially important when they change over time

Facilitators notes:


Oneofthemostdifficultaspectsofcaringfortheresidentwhocannotcommunicate(orhascognitivedeficitssuchasadvanceddementiaisidentifyingwhethertheyareexperiencingpain.

Themosteffectivemethodistoobservetheirbehavioursandfacialexpressions.

Discuss the differences in facial expressions.

See: Recognise and assess painAbbey Pain Scale

Vocalisation

•whimpering,groaning,crying

Facial expression

•lookingtense,frowning,grimacing,looking frightened

Changes in body language

•fidgeting,rocking,guardingpartofthebody,withdrawn

Behaviour changes

•increasedconfusion,refusingto

eat,alterationinusualpatterns

Physiological changes

•perspiring,flushedorpaleskin,abnormaltemperature,pulseorblood pressure

Physical changes

•skintears,pressureareas,arthritis,contractures,previousinjuries

Scored absent, mild, moderate or severe


Vocalisation

• whimpering, groaning, crying

Facial expression

• looking tense, frowning, grimacing, looking frightened


• fi dgeting, rocking, guarding part of the body, withdrawn

Behaviour changes

• increased confusion, refusing to

eat, alteration in usual patterns


• perspiring, fl ushed or pale skin, abnormal temperature, pulse or blood pressure

Physical changes

• skin tears, pressure areas, arthritis, contractures, previous injuries

Scored absent, mild, moderate or severe

Facilitators notes:


A common assessment tool for residents with cognitiveimpairmentistheAbbeyPainScale.

Itgivesascoreoutof18thatcanbecompared overtime.

If careworkers document pain levels in your facility hand out the assessment form as an example.

Mostpaininolderpeopleisrelatedtoactivity. The assessment is best undertaken when they are moving,transferring,beingturnedinbed;notwhenthey are at rest.

Vocalisation

Whimpering,groaning,crying

Facial expression

Lookingtense,frowning,grimacing,lookingfrightened


Fidgeting,rocking,guardingpartofthebody,withdrawn

Behaviour changes

Increasedconfusion,refusingtoeat,alterationinusual patterns


Perspiring,flushedorpaleskin,abnormaltemperature,pulseorbloodpressure

Physical changes

Skintears,pressureareas,arthritis,contractures,previousinjuries

Say: Report your assessment

Be SPECIFIC when reporting pain to a nurse

Immediately report ANY severe or worsening pain to the nurse

Do NOT wait to see if it gets better


Be SPECIFIC when reporting pain to a nurse

Immediately report ANY severe or worsening pain to the nurse


Facilitators notes:


Emphasise:

Provideclearappropriateinformationwhendiscussing or documenting the incidence or assessment of pain.

What to say

‘MrsSappearstohavepain.Shegrimaceswhenwetransfer her from sit to stand. This is not her normal behaviour.Ithashappenedthreetimestodaysofar.Shesaysitisanewpain’.

Is much better than:

‘MrsShasgotpain.Youneedtoseehertosortitout’.

Sometimes it is an emergency

Ifaresidentratestheirpainassevere,ortheyreportchestpainsanddifficultybreathing:treatitasanemergency and call a nurse immediately.

Do: Manage the pain

Manual handling

•comfortablepositioning

•taketimetopositionliftersand otherequipmenttopreventpain

•preventtwistingorstretchingofjointsormuscles

Massage and other therapies

Always provide care as directed in the resident’s care plan.

If unsure, speak to the nurse.

Do: Manage the pain

Manual handling

• comfortable positioning

• take time to position lifters and other equipment to prevent pain

• prevent twisting or stretching of joints or muscles

Massage and other therapies


If unsure, speak to the nurse.

Facilitators notes:

Do: Manage the pain

Non-pharmacological

Careworkershavetheabilitytohelpmanagearesident’spainwithsomesimpleyetveryeffectiveactivities.

Besuretothinkaboutthefollowingwhenyounextprovidecaretoaresident:

•Istheresidentlyingorsittinginacomfortableposition?

•Doyoutakethetimetopositionliftersandotherequipmenttopreventpain?

•Doestheresidenthavetotwistorstretchtheirjointsor muscles abnormally when being transferred?

•Canyouthinkofanyotherinterventions?

Massageandothertherapiescanproviderelief for residents.

Emphasise


If unsure about any aspect, speak to the nurse.

What you do can lessen the amount of pain medication a resident may need.

Do: Manage the painWhat will the nurse or doctor do?

Analgesic medications

Simple

•paracetamol

Strong

•Morphine,fentanyl,oxycodone,buprenorphine (Norspan)

Consider waiting > 30 minutes after analgesic medication before providing any care that is known to cause pain or discomfort.

Superficial heat (NOT cold)

Education (resident and family)

TENS machine

Referral to other health professionals


Analgesic medications

Simple

• paracetamol

Strong

• Morphine, fentanyl, oxycodone, buprenorphine (Norspan), tramadol

Consider waiting > 30 minutes after analgesic medication before providing any care that is known to cause pain or discomfort.

Superfi cial heat (NOT cold)

Education (resident and family)

TENS machine


Facilitators notes:


Medications have an important role in managing many types of pain

Opioids(e.g.morphine,oxycodone,norspanorfentanyl) are a type of strong analgesic.

Sometimesresidents,familymembersandevenagedcarestaffmayhaveconcernsaboutthesemedications.

Itisimportanttoknowthat,whenusedcorrectly,opioid medicines:

•donotleadtoaddictionordependence

Opioidmedicinesarenotaddictivewhenused forpain.Addictiononlyoccurswhenpeoplehave no pain and they abuse opioid medicines.

•donothastendeath Morphine and other opioid medicines are for improvinglife—nothasteningdeath.Somepeoplefear that being prescribed opioid medicines means thatthey’reclosertotheend.However,relievingpainchangesthequalityoflife—notitslength.

•donotcauseterribleside-effects Allmedicinescanhavesideeffects.Thesideeffectsofopioidmedicines(constipation,drowsiness,nausea,drymouth)areusuallymanageable.

Emphasise

Considerwaitingatleast30minutesafteraresidenthasbeengivenanalgesicmedicationbefore providinganycarethatisknowntocausethem pain or discomfort.


•physiotherapist

•occupationaltherapist

•painclinic

•specialistpalliativecare.

Write: Document your actions

Review: Evaluate and reassess as necessary

If you write in clinical notes or on assessment charts

Avoidgeneralstatements!

Bespecific

Evaluate your care

Q:Didithelp?

Yes:keepdoingit

No: tell the nurseInsanity = doing the same thing over and over again and expecting different results. Albert Einstein




Avoid general statements!

Be specifi c

Evaluate your care

Q: Did it help?

Yes: keep doing it

No: tell the nurseInsanity = doing the same thing over and over again and expecting di� erent results. Albert Einstein

Facilitators notes: Facilitators notes:



Documentation

Ifcareworkersdocumentintheclinicalrecordorhandoversheets,emphasisethattheyshouldbeasdetailedaspossible,avoidinggeneralisedstatements.

Example

Insteadof‘witheffect’or‘effective’,write: ‘Residentstatespainhasreducedto2/10score (was5/10)’.

Afterhelpingtorelieveorpreventpain,consider:

•Didithelp?

•IfYes:keepdoingit,regularly!

•IfNo:tellthenurse

Insanity=doingthesamethingoverandoveragainandexpectingdifferentresults.AlbertEinstein

Facilitators notes:

Dyspnoea

Dyspnoea

Dyspnoea

‘It’s funny, but you never really think much about breathing, until it’s all you ever think about.’ Tim Winton (Breath)

breathlessness or shortness of breath

an awareness of uncomfortable breathing

=

Dyspnoea

Dyspnoea


breathlessness or shortness of breath

an awareness of uncomfortable breathing

=

Facilitators notes:

Dyspnoea

Scope:


Careworkers (assistants-in-nursing)

Materials Needed:

Oxygennasalspecs

Learning Objectives


•definedyspnoeaasanawarenessof uncomfortable breathing

•identifydyspnoeainaresident

•implementnon-pharmacologicalstrategieswithin a careworkers scope of practice for a resident with dyspnoea

•haveabasicunderstandingofwhichmedicationsare used to treat dyspnoea

•understand,onabasiclevel,theinterventionsthatnursing and medical staff may utilise including medications.

Read the quote by Tim Winton out loud.


QuoteisfromAustralianauthorTimWinton’sbookBreathpublishedin2008byPenguinbooks

Ask participants if they have ever been severely short of breath.

What did it feel like?

Can they identify with the quote?

See: Recognise and assess dyspnoea

Dyspnoea

Dyspnoea

Anxiety Panic

Rapid and/or laboured breathing

Cough

Increased sputum

Wheeze

Chest pain

Fatigue

Panic

•oftenworsensasdeathapproaches

•impairsADLs,mobility&socialisolation

•isfrighteningforresidentandfamily


Dyspnoea

Dyspnoea

Anxiety Panic

Rapid and/or laboured breathing

Cough

Increased sputum

Wheeze

Chest pain

Fatigue

Panic

• often worsens as death approaches

• impairs ADLs, mobility & social isolation

• is frightening for resident and family


Ask:

What might you notice in a resident that could be related to dyspnoea?

•rapidand/orlabouredbreathing

•cough

•sputum

•wheeze

•chestpain

•fatigue

•panic.

Often anxiety is a major component of dyspnoea.

Dyspnoeatriggerspanic,andpanicexacerbatesdyspnoea,sothepatternbecomescyclical.

Dyspnoeacanimpairaresident’sactivitiesofdailyliving,limitmobility,increaseanxiety,andcanleavethem feeling fearful and socially isolated.

•Itcanalsobeasignofadeterioratingcondition inresidentsreceivingapalliativeapproach.

•Dyspnoeamayalsobeadistressingand frightening symptom for the family. This can leadtoincreasedanxietyfortheresidentwhich may increase their dyspnoea.

Facilitators notes:

See: Recognise and assess dyspnoea severity

Ask

“How bad is your shortness of breath?

Givemeascore outoften”

or

‘Whichofthesewordsdescribes how bad your shortnessofbreathis?’

No pain

Worst possible pain

Mild pain

Moderate pain

Severe pain

Very Severe pain

No shortness of breath

Worst possible shortness of breath

Moderate shortness of breath

0 1 2 3 4 5 6 7 8 9 10

No SOB Worst possible SOB

Mild SOB

Moderate SOB

Severe SOB

Very Severe SOB


Ask

“How bad is your shortness of breath?

Give me a score out of ten”

or

‘Which of these words describes how bad your shortness of breath is?’

No pain

Worstpossible pain

Mildpain

Moderatepain

Severepain

VerySeverepain

No shortnessof breath

Worst possibleshortness of breath

Moderate shortnessof breath

0 1 2 3 4 5 6 7 8 9 10

No SOB Worstpossible SOB

MildSOB

ModerateSOB

SevereSOB

VerySevereSOB


Severity

UseaRatingScale

ASK

‘Onascaleofzeroto10,withzeromeaningnoshortnessofbreath,and10meaningtheworstshortnessofbreathpossible,howmuchshortness ofbreathdoyouhaverightnow?’

OR:

Gettheresidenttolookatavisualscalewhichshould use large clear letters/numbers and be presented under good lighting.

Please note: while dyspnoea is the term health professionalsuse,itisbettertorefertoitasbreathlessness when talking to residents or family members.

Note: Some residents may not be able to understand thesequestionsduetocognitiveimpairmentordifficultycommunicating.Instead,taketimetoobservetheirbreathingrateandanyresulting impactontheirmood,sleeporfunction

Facilitators notes:


Be SPECIFIC when reporting information to a nurse

Immediately report ANY severe or worsening breathing problems to the nurse




Immediately report ANY severe or worsening breathing problems to the nurse



Emphasise:

Provideclearappropriateinformationwhendiscussing or documenting anything about the residents abnormal breathing to a nurse.

This will allow them to decide how urgently they need toreviewtheresident.

Ask

“Whichofthefollowingwouldbemosteffective?”

Careworker to Nurse:

‘Bobappearstobeshortofbreath.Hecannotwalk tothediningroomwithouthavingtostoptwicetocatch his breath. He says it has been a problem for afewdaysnow.’


‘Bobcantbreathproperly,pleasecomeand reviewhim.’

Justbecausearesidentrequiresapalliativeapproachdoes not mean that dyspnoea is normal or that nothing can be done.

Problems like asthma or cardiac chest pain can become worse very quickly and early detection of an episode is very important.

Facilitators notes:

Do: Manage the dyspnoea

Increase air movement

•opendoorsandwindows

•fans

Prevent overheating and claustrophobia

•exhaustfaninbathroom

•deflecttheshowerwater away from the face

Reduce exertion

•frequentrestbreaks

•don’trush

Position resident appropriately

Always provide care as directed in the resident’s care plan.If unsure, speak to the nurse.


Increase air movement

• open doors and windows

• fans

Prevent overheating and claustrophobia

• exhaust fan in bathroom

• defl ect the shower water away from the face

Reduce exertion

• frequent rest breaks

• don’t rush

Position resident appropriately

Always provide care as directed in the resident’s care plan.If unsure, speak to the nurse.


Emphasise

Focusingonthesemanagementstrategiescanoftenhelp the resident decrease the need for medication andoxygen.

•Increaseairmovementaroundtheresident– opendoorsandwindows,usebedsidefans.

•Preventoverheating–exhaustfaninbathroom, cool face cloths.

•Deflecttheshowerstreamawayfromtheface.

•Usestrategiestoadaptphysicalactivitytoreducetheneedforexertion.

•Positionappropriately–proppinguptheresidentwith pillows.

Demonstrate sitting forward over a pillow or table to expand chest cavity.

Facilitators notes:

Dyspnoea

Dyspnoea

Anxiety Panic


•reassurance

•calmpresence

•listenempathically

•slowdown!

Dyspnoea

Dyspnoea

Anxiety Panic


• reassurance

• calm presence

• listen empathically

• slow down!


•Fearandanxietyaboutnotbeingabletobreathe isveryrealandcanactuallyincreaseshortness of breath.

•Listenempathicallytotheresident’sconcerns.

•Trynottorushactivities(ashardasthatiswhenyouarebusy!)

Emphasise Again

Focusing on these management strategies can often help the resident avoid medication and oxygen.

Facilitators notes:

Do: Manage the dyspnoeaWhat will the nurse or doctor do?

Opioids

•decreasethefeelingofdyspnoea

Benzodiazepines

•canhelpwiththesevereanxiety

Oxygen

•fewresidentsbenefitfromoxygen

•onlynursesstartoxygenorchanges flow rate

•mouth/nasal/skincarebecomesmore important


Opioids

• decrease the feeling of dyspnoea

Benzodiazepines

• can help with the severe anxiety

Oxygen

• few residents benefi t from oxygen

• only nurses start oxygen or changes fl ow rate

• mouth/ nasal / skin care becomes more important


Careworkers do not need to know about medications inanydetail.Theycanhoweverobservetheeffectsandsideeffectsofmedications.

Opioids (like morphine)

•Arenotjustfortreatingpain.

•Someresidentsmayrequirethemregularlyoronlywhen breathing worsens.

•Opioidsdecreasethefeelingofdyspnoeaanddecreaseoxygenconsumption.

Facilitators notes:

Benzodiazepines (like diazepam)

Canhelpwiththeanxietyandpanicbutdonot bythemselveshelpthedyspnoea.

Oxygen

•Fewresidentswithdyspnoeawillbenefit fromoxygen.

•Beingshortofbreathdoesnotmeanthat aresidentneedsoxygen.

•DoNOTstartoxygenyourselforchange the flow rate.





Bespecific

Evaluate your care

Q:Didithelp?

Yes:keepdoingit






Be specifi c

Evaluate your care

Q: Did it help?

Yes: keep doing it




Documentation


Example

Insteadof‘witheffect’or‘effective’,write: ‘Residentstatesdyspnoeahasreducedto2/10score(was5/10)’.

Afterhelpingtorelieveorpreventdyspnoea,consider:

•Didithelp?




Facilitators notes:


Towards the end of life the body begins to shut down because of disease and the dying process not because of a lack of food and liquid.

‘Not eating/drinking’ does not cause the dying process

‘Not eating/drinking’ is part of the dying process


Towards the end of life the body begins to shut down because of disease and the dying process not because of a lack of food and liquid.

‘Not eating/drinking’ does not cause the dying process

‘Not eating/drinking’ is part of the dying process

Nutrition and hydrationFacilitators notes:

Scope:


Careworkers (Assistants-in-nursing)

Materials needed

Subcutaneous cannula (intima or similar)

Learning Objectives


•Appreciatethatnoteatingordrinkingispartof the dying process rather than the cause.

•Reportanddocumentcommonproblemsrelating to nutrition and hydration at the end-of-life.

•Describethepositiveandnegativeaspectsofartificialnutritionandhydration.

•Understand,onabasiclevel,theinterventionsthatnursing and medical staff may utilise.

Key Points

•Artificialnutritionorhydrationisgenerallyconsidered to be a life sustaining measure or medical treatment.

•Attheend-of-life,itisimportanttorememberthattheperson’sbodyisbeginningtoshutdownbecauseofthediseaseanddyingprocess, not because of the absence of food and liquid.

•Familymembersmayfinditdifficultto distinguishbetween‘noteating’aspartofthe dyingprocessand‘noteating’asbringingabout the dying process.

•Justbecausesomethingisreversibledoesnotmeanitshouldbereversed.Decisionsneedtobemade considering the residents prognosis and any previousdecisions/wishesaboutlifesustainingcare.

See: Recognise and assess nutrition issues

•decreasedneedfor“energy”

•poorappetite

•difficultyswallowing

•oral/mouthproblems


• decreased need for “energy”

• poor appetite

• diffi culty swallowing

• oral/mouth problems


Facilitators notes:

Residentsrequiringapalliativeapproachfrequentlylose interest in eating.

Theirpoorappetitemaysimplybebecausetheyhavea decreased need for energy.

Functionalissuescanalsobepresent:

•difficultyswallowing

•inabilitytomanagecutlery,cupsetc.

Other potential problems:

•medicationsideeffects forexample,nausea,constipation

•emotionalproblems;depression,anxiety

•swallowingdisorders

•oralfactors

•notculturallyappropriatefood

•wanderingandotherdementia-relatedbehaviours

•metabolicproblems

•entericproblems(boweldoesnotabsorbnutrients)

•sociallyinappropriatefoodorenvironment,lackofinteraction,inappropriatepositioningofresident.

See: Recognise and assess hydration issues

Dehydration? Not drinking enough?

•drymouth

•sunkeneyes

•dizziness

•headaches

•decreasedurination

•weakness

OR

•mouthbreathing

•medicationsideeffects

•prolongedbedrest

•oxygentherapy

•oralsupplements


Dehydration? Not drinking enough?

• dry mouth

• sunken eyes

• dizziness

• headaches

• decreased urination

• weakness

OR

• mouth breathing

• medication side eff ects

• prolonged bed rest

• oxygen therapy

• oral supplements


Ask the participants:

‘What do you see when some one is dehydrated?’

•drymouth

•sunkeneyes

•dizziness

•headache

•decreasedurination

•weakness.

Additionally there can be:

•dryskin

•drymucousmembranes

•dryfurrowedtongue

•lowbloodpressureanddizzinesswhenstanding

•cramps

•irritability

•drowsiness

•weightloss

•disorientation.

Astheresidentapproachestheendoflife,thesemayalso be caused by:

•prolongedbedrest

•sideeffectsofmedications

•mouthbreathing

•supplementaloxygenadministration

•theuseoforalsupplements.

Emphasise

These do not respond to simply increasing the intake of fluids either orally or by artificial means.

Facilitators notes:



Immediately report ANY choking or new swallowing problems




Immediately report ANY choking or new swallowing problems


Facilitators notes:


Emphasise:

Residentsgetthebestoutcomeswhenyouprovideclear information when discussing or documenting nutrition or hydration issues.

Provideclearappropriateinformationwhendiscussingor documenting nutrition / hydration issues.

What to say

Careworker to RN.

‘MrsSappearstobehavingtroublewithherbreakfastthis morning. She was coughing. She says she has had sometroubleswallowingforafewdays.’


‘MrsScouldn’teatherbreakfast.Youneedtoseehertosortitout.’

Do: Manage nutrition issues

Oral nutrition is preferable

•requiresdiligenthandfeeding

•offersmallermorefrequentmeals

•don’trushorforcefeed

•oralcarebecomesapriority



• requires diligent hand feeding

• off er smaller more frequent meals

• don’t rush or force feed

• oral care becomes a priority

Facilitators notes:



•Thisrequiresdiligenthandfeedingtoremaineffectiveastheresidentdeteriorates.

•Smallermorefrequentmealsaremoreappropriatethan three larger more traditional offerings.

•Selectadietbasedonresidentpreferences, lifelongfoodhabitsandidentificationof swallowing problems.

•Consultingadieticianversedinthepalliativeapproachmaybeofbenefit.

•Whenfeedingcauseschoking,nutritioncanbeprovidedinliquidformthathasbeenthickened with proprietary agents.

Do: Manage nutrition issuesArtificial nutrition

Positives / Benefits

•beingseentobedoingsomething

Negatives / Burdens

Does not:

•prolonglife

•improvecomfort

•improvequalityoflife

•preventpneumonia

•improvenutrition

•decreasepressuresores

Do: Manage nutrition issuesArtifi cial nutrition

Positives / Benefi ts

• being seen to be doing something

Negatives / Burdens

Does not:

• prolong life

• improve comfort

• improve quality of life

• prevent pneumonia

• improve nutrition

• decrease pressure sores

Facilitators notes:

Do: Manage nutrition issuesArtificial nutrition

Artificialnutritionisusuallyadministeredthrough anentericgastrostomy(PEG)tube.

There is no evidence that enteral tube feeding:

•prolongslife

•improvescomfortorqualityoflife

•preventsaspirationpneumonia

•leadstobetternourishment

•decreasestheriskofpressuresores.

A swallowing assessment is mandatory if there is any signofdysphagia.Registeredspeechpathologistsshould be consulted as necessary.

Do: Manage hydration issuesArtificial hydration

Positives / Benefits

•canhelpsomereversibleproblems

•seentobedoingsomething

Negatives / Burdens

•doesnothelpdrymouth

Can worsen:

•vomiting

•dyspnoea

•respiratorysecretions

•oedema/swelling

•ascites

Do: Manage hydration issuesArtifi cial hydration

Positives / Benefi ts

• can help some reversible problems

• seen to be doing something

Negatives / Burdens

• does not help dry mouth

Can worsen:

• vomiting

• dyspnoea

• respiratory secretions

• oedema / swelling

• ascites

Facilitators notes:

Do: Manage hydration issuesArtificial hydration

Not normally used in the terminal phase when aresidentisexpectedtodiewithin48–72hours.

May be useful for time limited use when dehydration iscausedbyapotentiallyreversiblecause:

•overtreatmentofdiuretics

•unintendedsedationfrommedications(opioidsetc)

•recurrentvomitingordiarrhoea.

Mostappropriatelyadministeredviathesubcutaneousroute (hypodermoclysis).

If you have a subcutaneous cannula such as an intima, show participants.

Fluidaccumulationmaybeanadverseeffect ofartificialhydrationatend-of-life

•increasedurinaryoutput

•increasedfluidinGItract–vomiting

•pulmonaryoedema,pneumonia

•respiratorytractsecretions

•ascites.





Bespecific

Evaluate your care

Q:Didithelp?

Yes:keepdoingit






Be specifi c

Evaluate your care

Q: Did it help?

Yes: keep doing it


Facilitators notes:



Documentation


Example

Insteadof‘atewell’or‘wellhydrated’,write: ‘Residentate3spoonfulsofsoftcustardanddidnothaveanyswallowingproblems.’or: ‘Residentacceptingsipsoffluid.Saysshestillfeelsthirsty.Tonguenotasdryasthismorning’.

Foranyinterventionsrelatedtonutritionorhydration,consider:

•Didithelp?

•IfYes:keepdoingit



Facilitators notes:

Oral Care

Oral Care A Palliative Approach in Residential Aged Care

A healthy mouth is…

•clean

•intact

•moist

•notinfected

•notpainful

Oral Care A Palliative Approach in Residential Aged Care

A healthy mouth is…

• clean

• intact

• moist

• not infected

• not painful

Facilitators notes:

Oral Care

Scope:


Careworkers (assistants in Nursing)

Materials Needed:

•torch

•tonguedepressorandtoothbrush

•disposablegloves

•mouthswabs.

Learning Objectives


•describewhatisrequiredforahealthymouth

•beabletosimplyassesstheoralhealthofaresident

•knowwhattodoifyoufindsomethingabnormal

•providestandardprotectivecareforresidentswiththeir own teeth or dentures

•provideoralcareforaresidentintheterminalphaseof their life who cannot swallow.

Ask

Whatdoweneedamouthfor?

Answer:

•communicating:talking,smilingetc.

•chewing

•swallowing

•tasting

•kissing!

In order to do these we need a healthy oral cavity that is:

•clean

•intact

•moist

•notinfected

•notpainful.

Careworkers have a key role in helping residents who require a palliative approach to maintain their oral health.

See: Recognise and assess

Look:

•everymealtime

•whencleaningteeth/dentures

•performingmouthcare.

•Lips

•Tongue

•Gumsandtissues

•Saliva

•Teeth/Dentures

•Cleanliness


Look:

• every meal time

• when cleaning teeth/dentures

• performing mouth care.

• Lips

• Tongue

• Gums and tissues

• Saliva

• Teeth/ Dentures

• Cleanliness

Facilitators notes:

Careworkers are most likely to notice problems as they:

•aretheonesthatprovidemouthcare

•feedtheresident

•spendmosttimewiththeresident.

Look at the:

•lips

•tongue

•gumsandtissues

•saliva

•teeth/dentures

•cleanliness.

Look:

•everymealtime

•whencleaningteeth/dentures

•performingmouthcare.



•badbreath

•soremouthandgums

•lipblisters/sores/cracks

•difficultyeating

•brokenteeth

•bleedinggums

•paininmouth/lips

•tonguecoatedorabnormalcolour

•excessivefoodleftinmouth

•mouthulcer

•refusingoralcare

•swellingofface/mouth

•denturebroken/lost


• bad breath

• sore mouth and gums

• lip blisters/sores/cracks

• diffi culty eating

• broken teeth

• bleeding gums

• pain in mouth/lips

• tongue coated or abnormal colour

• excessive food left in mouth

• mouth ulcer

• refusing oral care

• swelling of face/mouth

• denture broken/lost

Facilitators notes:


Careworkers are ideally suited to noticing problems during feeding or oral care.

Need to report problems to nursing staff if they are evenslightlyworried.

Don’t assume someone else has already reported it.

Emphasise

Some of these issues can begin as minor problems buthavethepotentialtodevelopintosignificantonesresulting in decreased quality of life for the resident.

•badbreath

•soremouthandgums

•lipblisters/sores/cracks

•difficultyeating

•brokenteeth

•bleedinggums

•paininmouth/lips

•tonguecoatedorabnormalcolour

•excessivefoodleftinmouth

•mouthulcer

•refusingoralcare

•swellingofface/mouth

•denturebroken/lost

Do: Manage oral careStandard protective care

Brush Morning and Night High Fluoride Toothpaste on Teeth

Soft Toothbrush on Gums, Tongue and Teeth Antibacterial Product After Lunch

Keep the Mouth Moist Cut Down on Sugar


Brush Morning and Night High Fluoride Toothpaste on Teeth

Soft Toothbrush on Gums, Tongue and Teeth Antibacterial Product After Lunch

Keep the Mouth Moist Cut Down on Sugar

Facilitators notes:


Standardprotectivecareshouldbeprovidedforallresidentsrequiringapalliativeapproachwho can still eat and drink.

Own Teeth

•highfluoridetoothpaste(5000ppm)morningandnight

•softtoothbrushtobrushteeth,gumsandtonguemorning&night

•antibacterialproductafterlunch

•keepmouthmoist–drinkwateraftermeals,medications&otherdrinksandsnacks.

Dentures

•labeldentures

•brushdenturesmorningandnightusingmildsoap

•rinsewellunderrunningwater

•brushgumsandtonguewithsofttoothbrushmorning and night

•removedenturesovernight,cleanandsoakinwater

•disinfectdenturesweekly

•encourageresidenttodrinkwateraftermeals,medications&otherdrinksandsnacks.

Do: Manage oral careSpecific problems

Dry Mouth

Moisten oral cavity

Water-basedmoisturisertolips

Discourage strong drinks

Reducecaffeine

Stimulate saliva

Encourage resident to drink water

Saliva substitutes

Pain or Ulceration

Rinse or swab mouth with warm saline

Check denture fitment

Avoid spicy or acidic foods or food with sharp edges

Offercold,softfood

Local or systemic analgesics as required

Medical review if not resolved within 7 days

Do: Manage oral careSpecifi c problems

Dry Mouth

Moisten oral cavity

Water-based moisturiser to lips

Discourage strong drinks

Reduce ca� eine

Stimulate saliva

Encourage resident to drink water

Saliva substitutes

Pain or Ulceration

Rinse or swab mouth with warm saline

Check denture fi tment

Avoid spicy or acidic foods or food with sharp edges

O� er cold, soft food

Local or systemic analgesics as required

Medical review if not resolved within 7 days

Facilitators notes:

Do: Manage oral careSpecific Problems

Dry Mouth (Xerostomia)

•moistenoralcavitywithfrequentrinsingand sipping of water

•waterbasedmoisturisertolips

•discouragestrongcordial,juicesorsugarydrinks

•reducecaffeine

•stimulatesalivawithtoothfriendlylollies

•encourageresidenttodrinkwateraftermeals,medications and other drinks and snacks

•salivasubstitutes:waterspray,oralbalancegel or liquid.

Pain or Ulceration

•rinseorswabmouthwithwarmsalinethreetofourtimes/dayuntilresolved

•checkdenturefitment

•avoidspicyoracidicfoodsorfoodwithsharpedges

•offercold,softfood

•localorsystemicanalgesicsasrequired

•medicalreviewifnotresolvedwithin7days.

Emphasise

Follow the residents care plan.


Coated / Dirty tongue, mucosa or teeth

Remove debris

Mouth rinses

Brush tongue

Infection

Treat the cause

Replace toothbrush

Disinfect dentures daily

Do: Manage oral careSpecifi c Problems

Coated / Dirty tongue, mucosa or teeth

Remove debris

Mouth rinses

Brush tongue

Infection

Treat the cause

Replace toothbrush

Disinfect dentures daily

Facilitators notes:


Coated tongue, mucosa or teeth

•removedebriswithsofttoothbrushormouthswab

•mouthrinseswithwaterorwarmsaline4times/day

•brushtonguewithsofttoothbrush

Infection

•treatthecauseasprescribedbyGPordentist

•replacetoothbrushbeforetreatmentcommencesand again when complete

•disinfectdenturesdailyuntilresolved

Emphasise

Follow the residents care plan

Do: Manage oral careEnd of life (terminal) phase

As a resident approaches death they lose the ability to feedthemselvesorhaveadrink.


As a resident approaches death they lose the ability to feed themselves or have a drink.

Facilitators notes:


As a resident approaches death they lose the ability to feed themselves or have a drink.

Eventuallyswallowingbecomesdifficultandunsafe.Functionallytheycannotcleantheirteethororalcavitybythemselves.

Oftenthisiswhena‘mouthcare’trolleyortrayisseenintheresident’sroom.

Emphasise

Careworkers should provide oral care every time they enter the residents room

•cleanand/ormoistenthemouthwithaswab

•checkthelips,applymoisturiser

•lookforanyproblemsasdescribedearlierin this talk.

When a resident can no longer eat or drink safely at the end of life:

•applydrymouthproductse.g.waterspray, oralbalancegelorliquidviamouthswabs

•useaspraybottleforproductssuchaschlorhexidine(alcoholfree)mouthwash

•applywaterbasedlipmoisturisers

•petroleumbasedproductscanincreaserisk of inflammation and aspiration pneumonia. Alsocontraindicatedduringoxygentherapy.

DO NOT USE MOUTHWASHES AND SWABS CONTAINING:

•lemonandglycerine

•sodiumbicarbonate(highstrength)

•preparationscontainingalcoholorhydrogenperoxide

•pineappleorotherjuices.

May damage oral tissues and increase risk of infection.





Bespecific

Evaluate your care

Q:Didithelp?

Yes:keepdoingit

No: tell the nurse

Insanity = doing the same thing over and over again and expecting different results. Albert Einstein





Be specifi c

Evaluate your care

Q: Did it help?

Yes: keep doing it

No: tell the nurse

Insanity = doing the same thing over and over again and expecting di� erent results. Albert Einstein

Facilitators notes:



Documentation


Example

‘MrsSappearstohaveaverydrymouth.Swallowinganythingmorethanwaterisdifficult.Hertongueisdry and has white spots and there are some cracks in the corners of her lips. She says it got much worse whenthestrongpainmedicationsbegan.’

Evaluation

Afterdeliveringoralcaretoaresident,consider:

•Didithelp?

•IfYes:keepdoingit



Delirium

Disorganised

•thinking •behaviour

Poor attention

•focusing •sustaining •shifting

Hallucinations and delusions

(possible)

Delirium

Disorganised

• thinking• behaviour

Poor attention

• focusing• sustaining• shifting

Hallucinations and delusions

(possible)

Delirium

Scope


•careworkers(assistants-in-nursing).

Learning Objectives


•definedeliriumintermsofitseffectonbehaviour,thinking and attention

•identifydifferencesbetweendeliriumanddementia

•identifyclinicalsignsofdelirium

•implementnon-pharmacologicalmanagementstrategieswithinacareworker’sscopeofpractice

•understand,onabasiclevel,theinterventionsthatnursing and medical staff may utilise including medications.

Key Points

Deliriumisaconditionwheretheresident’sbehaviourand thinking is disorganised.

Theystruggletofocus,sustainorshifttheirattention.

Sometimes hallucinations or delusions are present.

Deliriumisdistressingnotonlyfortheresidentbut for family and health care workers.

Deliriuminolderpeopleisoftenoverlookedandmisdiagnosed,especiallyattheend-of-life.

Facilitators notes:

Delirium

See: Recognise and assess delirium

Developsovershortperiodoftime

Fluctuates during the course of the day

Lasts usually for a few days but may be weeks

Causes:

•dehydration

•medicationsideeffects

•uncontrolledpain

•infections

Dementiaisdifferent


Develops over short period of time

Fluctuates during the course of the day

Lasts usually for a few days but may be weeks

Causes:

• dehydration

• medication side eff ects

• uncontrolled pain

• infections

Dementia is di� erent


Timeframe:

Deliriumdevelopsoverashortperiodoftime.

Generally fluctuates during the course of the day.

Deliriumusuallyonlylastsforafewdaysbutmaypersistforweeksorevenmonths.

Causes:

Deliriumisoftencausedbyacombinationoffactorsincludingdehydration,medicationsideeffects,uncontrolled pain and infections.

Dementia on the other hand is a long term impairment of thought processes (cognition) with clearconsciousnessthatdevelopsoveralongerperiod of time than delirium.

Read this aloud to the group:

Alfred who you see here has always been alert with only minor memory impairment.

Thisafternoonheisverydrowsy.Hemumblesthatheneedshelpto“catchthechickens”andkeepstryingto get out of bed.

Hecannottellyouwhereheisoridentifysignificantfamily members.

Three days ago he was diagnosed with a urinary tract infection.

Ask:

DoyouthinkAlfredmighthaveadelirium?

Facilitators notes:



Immediately report ANY changes in mental state or altered level of consciousness




Immediately report ANY changes in mental state or altered level of consciousness



Emphasise:

Anyneworworseningsignsofthoughtorbehaviouralways need to be reported to a nurse.

Be as clear and detailed as possible.

Ask:

Which do you think is better?

‘Alfredappearstobeconfusedanddrowsy.Hesayshewantstocatch“thechickens”andkeepstryingtogetoutofbed.Hewasn’tsurewhohisdaughterwaswhenshevisited.Inoticedtheurineinhisurinalbottleisverysmelly’.

OR

‘Alfredisconfused.Youneedtoseehimtosortitout’.

Facilitators notes:

Do: Manage the deliriumRemove hazards

Bed

•lowestposition

•cotsidesdown

•againstwall

Familiar objects and people

Lighting

Noise

Clock

Avoid room changes

Do: Manage the deliriumRemove hazards

Bed

• lowest position

• cot sides down

• against wall

Familiar objects and people

Lighting

Noise

Clock

Avoid room changes

Do: Manage the delirium

Sometimes it may be appropriate to treat the cause (if it is known).

Attheend-of-life,non-pharmacologicalstrategiesareoften better.

•appropriatelighting

•minimisenoiseespeciallyatnight

•provideaclockthattheresidentcansee

•avoidroomchangesandkeeppersonalandfamiliarobjectsinview.

Modifyenvironmenttominimiseriskofinjury e.g. low bed in the lowest position with cot sides down,bedagainstthewall,potentialhazardssuch asbedsidetablesremoved.

Ask:

ImagineyouareAlfredlyinginbedatnight.Itisdark,nooneisaroundandyouareconfused,frightenedandnotsurewhereyouare.Youhearloudnoisesinthecorridor that sometimes disturb you. Perhaps you want togetoutofbedtofindsomewherebettertobe.

Ask:

WhichofthesemeasurescouldtheydotodecreaseAlfred’sdistressandevenpreventthedeliriumgettingworse.

NoneofthemwillcureAlfred’sdeliriumbutmanywoulddecreasehisfearandanxiety.

Ask:

Whatelseapartfromenvironmentalstrategiesmighthelp? (turn the page to answer this)

Facilitators notes:


Resident Distress

AVOIDphysicalrestraint

Reassurance

Reorientation

Relaxation

Sufficientsleep

Manage pain

Spectacles and hearing aids

Interpreters

Family Distress

Explanation

Reassurance


Resident Distress

AVOID physical restraint

Reassurance

Reorientation

Relaxation

Suffi cient sleep

Manage pain

Spectacles and hearing aids

Interpreters

Family Distress

Explanation

Reassurance


Resident Distress

•addressanxiety -residentswithdeliriumareoftenveryfrightened

•managediscomfortorpain

•minimisesensorydeficitsbyproviding&assistingwithhearingandvisualaids n.b.cleanspectaclesandremovewaxdepositsinhearing aids. Check batteries are fresh.

•encouragepresenceofpeopleknowntotheresident–e.g.familyandfriendsandregular staff members

•reassureandreorientatetheresident

•explainandreassureregardingthepossible causes and management plan to the resident and their family

•AVOIDphysicalrestraint

•useinterpretersandcommunicationaidsforresidentswithculturally&linguisticallydiverseneeds

•promoterelaxationandsufficientsleep e.g.assistedby,massageand/orencouragingwakefulness during the day.

Family Distress

•explanationofthecauseifknown

•reassurance.

Emphasise

Focusingonthesemeasurescansometimeshelp theresidentavoidmedication.

Facilitators notes:

Do: Manage the deliriumWhat will the nurse or doctor do?

Treat the cause if appropriate

Minimise use of urinary catheters

Review medications

When nothing else works


Treat the cause if appropriate

Minimise use of urinary catheters

Review medications



Treat the cause if appropriate (often not appropriate in the terminal phase)

Minimise use of urinary catheters (discuss why)

Medications

•stopunnecessarymedications

•sometimesmedicationsareneededtoreducetheresident’sdistress iftheyareveryagitatedorhavinghallucinations

- Alfredbecameveryagitateddespitecareworkerstryingmanyof thesimplemeasuresintheabovelist.HisdaughterSarahwasalsoveryupsetseeingherfatheryellingatherandthestaff.

- Thenurseadministeredaninjectionofhaloperidolwhichwaseffectiveinreducinghisdistressandconfusion.Hereceivedanumber of doses which continued to help without any side effects.


Unfortunately,sometimesagitationanddeliriumintheterminalphasecausessuchseveredistressthatstrongsedativemedicationistheonlyappropriateintervention.

Facilitators notes:



Avoidgeneralstatements! Bespecific

Evaluate your care

Q:Didithelp?

Yes: keepdoingit





Avoid general statements! Be specifi c

Evaluate your care

Q: Did it help?

Yes: keep doing it




Documentation


Example

Insteadof‘witheffect’or‘effective’,write:‘‘Residenthas not hallucinated in the last two hours and has stoppedphysicallypluckingatthebedsheets’.

Afterhelpingtoimprovesafetyorrelievedistressofdelirium,consider:

•Didithelp?



Insanity=doingthesamethingoverandoveragain andexpectingdifferentresults. AlbertEinstein


Facilitators notes:

The Palliative Approach Toolkit - CareSearch · 2015-04-19 · These educational flip charts are...

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